Community Health Workers: A Way Forward

Journal of Management in Medicine

ISSN: 0268-9235

Article publication date: 1 March 2000



D’Souza, L. (2000), "Community Health Workers: A Way Forward", Journal of Management in Medicine, Vol. 14 No. 1, pp. 77-80.



Emerald Group Publishing Limited

A review of community health worker (CHW) programmes set in the context of health care reform, this slim volume covers three broad issues from a wide range of problems plaguing CHW programmes in the delivery of primary health care (PHC) since its inception in the 1970s. The authors assume an unequivocal stand on the worth of CHWs. The question is not whether they are of any value. As long as there are communities underserved by health services, CHWs will continue to have a important role in developing countries and, increasingly, in countries of the industrialised West. What is the way forward for these programmes, the authors ask, echoing concerns raised by experts almost a decade ago (Frankel, 1992).

There are sound reasons for reviewing national CHW programmes. Critics, not for the first time, are questioning their continued value in the face of overall improvement in health status indicators in many developing countries. At national and international levels health planners and decision makers are more aware than ever of the limitations of CHW programmes. Concern over population growth and environment has caused donor agencies to change their funding priorities. Concurrent social and economic changes, structural adjustment, expansion of the private medical sector, introduction of medical insurance and the continued growth of the pharmaceutical industry along with the emergence of new infectious diseases and re‐emergence of old diseases have all contributed significantly to health care reform. The review looks at the functioning of CHW programmes in the face of this reform.

Drawing on the vast amount of literature that has accumulated on the subject of CHW programmes, three main aspects of improving primary health care through CHW programmes have been reviewed in some detail. These are: relationships between communities, health services and CHWs, the infrastructure of district health systems and resource allocation.

First, the attitudes of communities and health service personnel toward the CHW is examined. While attributing many of the problems facing CHWs to deficiencies in these vertical relationships, practical suggestions have been made to removing barriers and strengthening the relationships. The examples cited have been successful in small scale programmes. How can community attitude towards the CHW change in large scale national programmes? How can communities develop a sense of ownership about the CHW programme? The imposition of user fees is suggested as a means of increasing community participation and resources. Can this be a just and practical solution in places where people are still dying in large numbers of conditions associated with extreme poverty?

Strong political commitment by communities (Frankel, 1992; Zhu, 1989) and the genuine support of national governments are pre‐requisites for the success of nationwide CHW programmes. As Walt (1990, p. 26) observed, “the policy of training barefoot doctors was an indigenous idea and fitted into the organisational structures of rural China”. This took place at a time when political commitment was high. Can such commitment be taught? Then who will teach the people? Werner (1981) suggested that CHWs can act as agents of change in their communities. Can the role of concientisation prescribed by Paulo Friere be cast onto the CHW? Indeed, can the small scale experiments that boast of such successes be replicated on a national scale? Is the commonly brief training given to the CHW sufficient for the role? Werner follows Friere’s approach to health. His books are explicitly political, though on the surface they may seem to be simple manuals for village health workers and their training (MacDonald, 1992, p. 159). Will governments and the health services they run for people support movements which will inevitably encourage people to demand the conditions essential for health and wellbeing?

The second part of this review looks at the district health system and primary health care delivery. Common problems associated with the health service structure, health management structure and health development structure are discussed. The health development structure, it is pointed out, is an under‐utilised source in the attainment of health through CHW programmes in developing countries. Representation of local groups in hillage health committees has been discussed along with their value and potential pitfalls.

Finally, the problems of resource allocation are analysed. One of the most important points brought out here is that the high re‐investment and maintenance costs of CHW programmes are not taken into account. Many of these are hidden costs and have been overlooked. Resources for sustaining such programmes have not, in many countries, been seriously investigated.

A serious omission in this study is the inadequate reference to the urban situation. Given the rate of urbanisation across the world and the prediction that most people born in the next 50 years will live eventually in cities, a discussion of the future of CHW programmes in the urban situation would have been appropriate.

Reviews of this nature necessarily draw on the well documented programmes and data compiled by governments. Inbuilt and on‐going research and standardisation of variables in CHW programmes across countries will greatly help in further planning, decision making and resource allocation while allowing for sharing of experiences across countries. At least it will eliminate unintentional errors like the inclusion of ICDS workers’ CHW programmes in India (see p. 3). Measured against the WHO definition of community health workers ICDS workers may not be considered as part of CHW programmes.

This review must be read by those in national governments and district health systems who have committed themselves to implementing CHW programmes and the delivery of affordable, accessible, available and appropriate primary health care. For those aid agencies who pledge their support to health care services in poorer countries this volume provides a realistic view of the actual costs of running CHW programmes and the problems of underestimating the budgets. Equally, the ideas and suggestions contained in this volume need dissemination to the CHW and programme managers in the field as well as the communities participating in the CHW programmes.


Frankel, S. (1992), The Community Health Worker: Effective Programmes for Developing Countries, Oxford University Press, Oxford.

Macdonald, J.J. (1992), Primary Health Care, Earthscan, London.

Walt, G. (1990), Just Another Pair of Hands: Community Health Workers, Open University Press, Buckingham.

Zhu, N. (1989), “Factors associated with the decline of the co‐operative health system and barefoot doctors in rural China”, Bulletin of the World Health Organisation, Vol. 67 No. 4, pp. 43141.

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